A Closer Look at OTC Painkillers

Turning to acetaminophen, ibuprofen and aspirin now and then is fine, but long-term use can damage organs.

Talking a low daily dose of aspirin has been a long time recommendation for heart health, and many of us pop a Tylenol or an Advil to knock out a headache, muscle ache, arthritis pain, or menstrual cramps. Because of the accessibility of over-the-counter (OTC) medications like aspirin, acetaminophen, and ibuprofen, many may think nothing of grabbing a pill to ease what ails us, or, in the case of aspirin, to actually improve our long term health and reduce our risk for disease.

Newer research is demonstrating a downside of OTC painkillers. Some studies suggest that taking these medications over the long run – even in low doses – may be associated with more health risks than benefits. And some can be serious. Here we’ll outline the new studies that have suggested that, while the risks may be rare, OTC medications are not as gentle and safe as we may be tempted to think.

Weighing Aspirin’s Bleeding Risks Against Its Heart Benefits

Organizations like the American Heart Association recommend aspirin for people who are at higher risk of cardiac issues such as heart attack or stroke. But since it is a blood thinner, aspirin is known to elevate risk of bleeding, which can be serious and could potentially outweigh its benefits.

Doctors agree that not everyone should take aspirin as a preventative measure to reduce heart risk, according to the authors of a new study, but there is little consensus about the point at which the benefits outweigh the risks, even for those at higher likelihood of having a cardiovascular event. A team of researchers looked at whether low dose aspirin taken over the long term reduced the risk of cardiac events in women above and beyond the risks it posed.

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Some of the participants in the aspirin group suffered from adverse bleeding problems, like gastrointestinal bleeding, peptic ulcers, or easing bruising.

The study set out to determine this balance point, by tracking the heart health over a decade of almost 28,000 women who had taken part in the Women’s Health Study. Half of the participants took an average of 100 mg of aspirin every other day; the other half took a “dummy pill” (placebo).

Overall, the risk of having a stroke, heart attack, or dying of a cardiac issue was reduced from 2.4 to 2.2% in the women who took aspirin, compared to the control group. This reduction is not huge. And some of the participants in the aspirin group suffered from bleeding problems, like gastrointestinal bleeding, peptic ulcers, or easy bruising.

Acetaminophen: Slow and Steady Doesn’t Always Win

It’s not only aspirin that’s under the magnifying glass. Many of us think that acetaminophen, such as Tylenol, is far safer than aspirin. But a recent study found that even low dose acetaminophen over the long term can be even more damaging to the body than a high single dose.

When researchers analyzed the records of 663 patients who had been treated for liver toxicity at a Scotland hospital, they found that 161 of them had taken a “staggered overdose,” a low, chronic amount, usually to deal with recurrent aches and pains like muscle aches, headache, and toothache. The continual use had damaged their livers, as their bodies struggled to remove the chemical day in and day out.

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Considering the number of people who use acetaminophen for common aches and pains such as arthritis, rethinking the dosing and marketing of the drug is likely a wise move.

Staggered overdose patients were also more likely to suffer brain and kidney as well as liver problems compared to patients who had taken a large single dose of acetaminophen. They were also at higher risk of having to be on a breathing machine – and, surprisingly, they had a greater risk of dying.

Appropriately, earlier this year the FDA urged all makers of acetaminophen to reduce capsule strength to 325 mg of the drug, and to display a Boxed Warning on the packaging, outlining the risk of liver damage. Considering the number of people who use acetaminophen for common aches and pains such as arthritis, rethinking the dosing and marketing of the drug is likely a wise move.

Acetaminophen for Kids: Dosing Problems

The use of acetaminophen in children has also been under scrutiny in recent months. Confusion about proper dosing for children has prompted the FDA to revamp dosing instructions on children’s acetaminophen. Labels will now include directions for dosing in children as young as 6 months and up (previously it had been two years and older). And labels will only indicate that acetaminophen should be used for fever reduction, not for pain, since according to the FDA there is just not enough evidence to warrant its use for pain in kids.

Doctors’ recommendations for proper use may also be different from the bottle’s label, since they can depend on the specific situation, which is another good reason to check with your pediatrician before giving your child medication.

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The Consumer Healthcare Products Association has also moved to make changes to the way children’s medications are mixed, so that the concentration of infants' and children’s acetaminophen will be the same.

Because the use of acetaminophen in children is still an ongoing debate, and because it may interfere with vaccinations' effectiveness, it’s important to talk to your child’s doctor to discuss the pros and cons of acetaminophen. Doctors’ recommendations for proper use may also be different from the bottle’s label, since they can depend on the specific situation, which is another good reason to check with your pediatrician before giving your child medication.

Ibuprofen: A Better Bet or Just as Risky?

Other recent research has looked into the safety of other go-to pain medications, like non-steroidal anti-inflammatory drugs (NSAIDs) including ibuprofen. Unfortunately, while it is generally safe, this common OTC painkiller also has its downside.

One study found that certain NSAIDs can pose significant risks to the heart: regular use of OTC ibuprofen was linked to greater risk of stroke – up to 29%, for both fatal and nonfatal forms. Other, newer research has found that use of OTC ibuprofen at very low doses may double the risk of miscarriage in the first trimester of pregnancy. The NIH warns that even ibuprofen and naproxen (Aleve) can cause bleeding, ulcers, heart attack, stroke, and sudden death. Aspirin and ibuprofen can also interfere with the action of antidepressants. The adverse events associated with NSAIDs are uncommon, but they do exist and can be unpredictable.

The Best Dose: Small and Infrequent

No medication is perfectly safe over the long term. As helpful as they truly are, even our beloved OTCs pose risks when taken over long periods of time, and the risks are not negligible. Easy accessibility and marketing make aspirin, acetaminophen, and NSAIDs appear mild and harmless, but this is an oversimplification.

And to the best of your ability, do the real things that improve heart health, rather than simply relying on a pill.

In the same way that we tend to think of “natural” products as being less risky than prescriptions, OTC medications might appear, at first glance, to be a gentler way of treating what ails us. But as these studies point out, they are all made of chemicals that affect various bodily systems for better and worse and can be difficult for the body to process and clear safely.

As important as it is to know that OTC medications carry risks, it would be foolish, however, to overlook their benefits. Most recently, a study presented at the American Stroke Association meeting in early February found that aspirin compared favorably with the blood thinner, Warfarin, in terms of its ability to protect against stroke. So, while it's clear this common OTC medication carries some genuine risks, it also brings benefits that should not be overlooked.

The best advice is likely to take small doses as infrequently as possible. And to the best of your ability, do the real things that improve heart health, rather than simply relying on a pill. Avoid saturated fat and exercise as long as your doctor doesn't warn against it. Talk to your doctor if you are concerned about dosage and the effects of intake over the long term.